In the corporate world of American health care, with its consolidating hospital chains and doctors’ groups, psychologists and other mental health therapists are still mostly Mom-and-Pop shops; they’ve built solo practices, hanging their own shingles, not unlike Lucy in the Peanuts gang: “Psychiatric Help 5¢, The Doctor Is In.”

But that business model is shifting from solo practices toward large medical groups, say mental health experts. The shift is propelled by the Affordable Care Act, which mandates mental health benefits in insurance coverage, and the 2008 mental health parity law, which requires private and public insurers to cover mental health needs just as they do medical conditions by charging similar co-pays, for example.

“It’s a big change for us. There is a loss of autonomy that a lot of therapists are frightened about.”

“It’s a big change for us,” said Barbara Griswold, a marriage and family therapist in San Jose. “I spent all of my life setting up this practice where I choose my clients, I choose my hours.”

In just the last few months, Griswold has weighed a new contract with a giant health insurer, warned other therapists to watch what they’re signing in payment negotiations and considered the extinction of her own solo practice. “The idea of me moving into an interdisciplinary practice where somebody else is taking care of my billing, and someone is choosing my clients for me —there is a loss of autonomy that a lot of therapists are frightened about,” Griswold said.

Organizations that advocate for mental and behavioral health, groups that long complained they were treated as second-class providers, have applauded the federal laws. “Some people have paid for mental health out of pocket because they didn’t have mental health insurance,” said Dr. Katherine Nordal, executive director for professional practice at the American Psychological Association. “I think now they’ll expect their providers to accept insurance.”

But inclusion into the mainstream has come with some unhappy caveats: Cash was simple. Patients used to paying $150 in cash for a therapy session will, with some limitations, be covered by their health plan.

That means many therapists will have to figure out innumerable insurance plans and byzantine billing codes for the first time. “A lot of people come to me and they’re almost falling apart,” said Griswold who wrote a book called, “Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance – and Whether You Should.” “It’s almost like a therapy session with these therapists. Seriously! I had a woman cry on my couch. She was like, ‘I don’t know how to do this!’”

Therapists who already accept insurance typically take a big pay cut since insurers negotiate fees that are about half of what they charge for cash visits. Blue Shield of California, for example, recently asked Griswold to accept a 10- to 30-percent discount off of her already discounted rate for patients who will buy health plans through the new online insurance marketplace. She refused and then wrote about the negotiations in her popular newsletter. “I put out in my newsletter, ‘Do you even know what you signed?’ And people wrote back, ‘Oh my God, I had no idea!’”

In many ways, therapists are encountering what medical doctors have complained about for years: the confusing and confounding – some say hostile – insurance bureaucracy that providers must tangle with in order to get paid. Therapists are expected to invest in expensive electronic billing software and electronic health records and comply with a tome of regulations.

“Just keeping up with all of that quite frankly is exhausting,” said Erica Savino Moffatt, a psychiatric nurse practitioner in Boston. “If you’re Jane Therapist hanging her shingle down the office from her home, it used to be the benefit was a better work-life balance and control over your immediate work environment. But a lot of that is lost in trying to track all of these logistics.”

The dizzying complexity of running a practice has meant more therapists are taking down their shingles, and consolidating with each other to share the burden, executives at national mental groups say. Or they are joining large medical groups in which mental health services are part of a continuum of care.

The changes are part of a remaking of a system that has long treated the mind as separate from the body. “If you look how many airlines there are today versus 10 years ago; if you look at hardware stores versus Home Depot and Lowe’s; it’s really a monopoly economy,” said Linda Rosenberg, president of the National Council for Behavioral Health. “And I think solo practitioners are going to be employees of big systems.”

In Tacoma, Wash., Dr. Barry Anton works as a clinical psychologist at Rainier Associates, an outpatient mental health clinic staffed by 17 therapists. Solo practitioners “might find it difficult to succeed in the new environment because the health care delivery system is evolving,” Anton said.

As insurance companies look to provide mental health care on a large scale, clinics like Rainier Associates are attractive partners. “It’s been very convenient and efficient for the insurance company to work with a bigger group,” said Anton. “We only have one tax ID number; we take care of all the credentialing; we take care of all the billing. They cut one check. It’s just more efficient for them.”

Psychologists, psychiatrists and other therapists in larger groups gain bargaining power as well and can demand higher reimbursement rates from insurance companies. “For those mental health practitioners who can develop group practices where they can provide a full range of services – from psychotherapy to family therapy to marriage therapy to medication management – they are going to be in a much better position to negotiate not only with commercial carriers but also with the federal government,” said Nordal of the American Psychological Association.

In addition to super-sizing mental health practices, mental health providers are beginning to play a bigger role at primary care clinics.

Savino Moffatt is a newly minted graduate who, instead of starting her own practice, saw where the future was headed: She works as a psychiatric nurse practitioner at a large clinic in Boston that is well positioned for the era of integrated medicine. She sits alongside internists and pediatricians who previously didn’t know where to turn to for psychological help with their patients. Now, Savino Moffit is just down the hall. “Once you say, ‘Hey, I’m here! I do psychiatry.’ And they kind of look at you like, ‘Oh thank goodness! I have a patient and I’m so worried!’”

Savino Moffit says she can identify mental health conditions like depression that might be masquerading as physical symptoms and which allows physicians to better serve their patients. It also can save the clinic from ordering costly and unnecessary tests, an important consideration for large medical groups that receive a set amount of money each month to cover all the needs of their patients.

Mental health experts say setting up these new business models will take time; that it’s a marathon, not a sprint. Barbara Griswold, sitting in her therapist’s chair at her office in San Jose, says that’s about the right speed. “I tend to think therapists overreact about change. We’re not really good with change, which is funny because we help people with change.”

Kaiser Health News (KHN) is a nonprofit news organization covering health care policy and politics. It is an editorially independent program of the Kaiser Family Foundation.

Author

Lisa Aliferis

Lisa Aliferis is the founding editor of KQED's State of Health blog. Since 2011, she's been writing and editing stories for the site. Before taking up blogging, she toiled for many years (more than we can count) producing health stories for television, including Dateline NBC and San Francisco's CBS affiliate, KPIX-TV. She also wrote up a handy guide to the Affordable Care Act, especially for Californians. Her work has been honored for many awards. Most recently she was a finalist for "Best Topical Reporting" from the Online News Association. You can follow her on Twitter: @laliferis

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California faces health care challenges seen across the country. At a time of intense focus on reform, "State of Health" explores these issues and more, bringing you stories of challenge and change in the Golden State. The blog is edited by Lisa Aliferis.